E&M coding - help please!

I am trying to do my first E&M audit - one of my providers saw a new patient to establish and he did an office note which states NEW PATIENT HERE TO ESTABLISH...........
He did a short history.......
He also stated - "Pap not due until July - come in then"
and
he did speak with her regarding conception plans, LMP, vitals and BMI - this is all documented with an office note.
He also no charged her since he did not do a full exam....my questions is - when she comes back in is she now established or new?

I think she should be charged because he saw her and he did do somewhat of an exam. I would collect all the data (HPI, Exam, and MDM) that he has and do an e/m level. And that way she would be established when she came back in. But I think the bottom line is that he did see tha pt. Hope this helps!

ShawnS

I agree she should be charged. Even if the physician did not do a complete exam, he should be able to charge by time, providing he recorded the amount of time spent with the patient. Then when the patient comes back in she is not considered a new patient.

However, I have had situations like this that put the coder in a sticky spot as to whether the patient is new or established. If the physician insist on not charging her for the first visit, I think you really should still consider her an established patient when she returns.

Disclaimer: Although AAPC staff members will monitor these forums periodically, we cannot be responsible for the information posted herein, nor guarantee its accuracy. Our members may discuss various subjects related to medical coding, but none of the information should replace the independent judgment of a physician for any given health issue. Please note that the opinions expressed here do not necessarily reflect those of AAPC.